How are UCLA Medical Group HMO/POS referral decisions made?
UCLA Medical Group utilization decision-making for HMO/POS members is based upon approved guidelines and appropriateness criteria from the United States Preventive Services Task Force, Health Plans, UCLA Medical Group, and other sources as well as the applicable Health Plan Evidence of Coverage. The outcome of any specific request may be approval, modification, or denial of a specific service. No individual, including the medical director and the utilization management staff conducting utilization reviews, receives a financial incentive for issuing an approval, modification, or denial of a coverage or service. There are no financial incentives that would encourage under-utilization of medical services. The criteria used in making a referral decision can be requested by a member, a person designated by the member, or by a member of the public by calling us at (310) 302-1300.
